Cardiovascular Daily wraps up the top cardiology news of the week

For newly diagnosed atrial fibrillation, being seen by a cardiologist was independently associated with better outcomes, according to results from the Veterans Health Administration TREAT-AF study reported in the Journal of the American College of Cardiology.

Among 184,161 nonvalvular cases seen by a primary care physician (60%) or cardiologist (40%) within 90 days of diagnosis, the adjusted likelihood of stroke was 8% lower, and mortality was 11% less likely if patients were seen by the specialist (both P<0.0001), although arrhythmia-related hospitalization was 38% more likely and myocardial infarction was 3% more likely. Analysis suggested that the stroke difference may have been due to more oral anticoagulation prescriptions written by cardiologists.

The researchers cautioned that the observational findings are hypothesis generating. And while an accompanying editorial noted various caveats, including possible self-selection bias, the writer concluded that the findings offer "an important statement that cardiologists play a critical role in framing the decisions that patients face when diagnosed with atrial fibrillation."

The editorial concluded: "Despite the growing administrative hurdles and outside noise for us and our patients, we cannot forget that as choice architects, our efforts may make all the difference."

Distressing to the Heart

Serious mental distress that lingers is associated with mortality risk among patients with stable coronary artery disease, a trial analysis reported in Heart.

In the Long Term Intervention with Pravastatin in Ischaemic Disease Trial, patients with a heart attack or admission for unstable angina reported mental distress as part of a general health questionnaire at 6 months and at 1, 2, and 4 years after the event.

Occasional or mild persistent distress showed no association with mortality. But the 3.7% of patients with persistent moderate or severe distress were almost four times more likely to die of cardiovascular disease and about three times more likely to die of any cause over a 12-year period than people who reported no distress at any of the assessment periods.

An accompanying editorial, however, cautioned that the health questionnaire used is outdated, contained no information on the specifics of distress, did not account for traumatic life events or socioeconomics, and (most importantly) could not address causality.

Still, psychological distress should be screened routinely and addressed with strict implementation of secondary prevention and referral to mental health professionals, the editorial concluded.

Family-Led Stroke Rehab

In India, where most stroke patients have no access to rehabilitation programs, a trial of family-led efforts -- started at the hospital and continued at home -- still did not improve functional outcomes, researchers reported in The Lancet.

In the ATTEND trial of 1,250 randomized patients, the 6-month rate of death or dependency was 47% with the intervention and among controls alike (P=0.87). Rehospitalization, mortality, and total non-fatal events likewise came out as similar between groups.

The researchers said that although so-called "task shifting" to the family might be an attractive solution for healthcare sustainability, especially in low-resource areas, the findings do not support that approach. However, looking at task shifting to healthcare assistants or team-based community care might be a good alternative for future research, the team suggested.

After turning up only 24 observational studies and no trials, the researchers concluded that the evidence provides a "highly uncertain" picture of the risk-benefit ratio due to "inconsistent and imprecise findings."

While the pooled findings suggested a modest 26% relative risk reduction of thrombosis with antiplatelet therapy and median 30% increased risk for major bleeding, large ranges were seen in all analyzed outcomes. In addition, the researchers said, the trials had moderate to serious risk of bias.

Low annual family income at ages 3 and 18 were independently and significantly associated with increased left ventricular mass index (1.5 g/m2.7 versus high socioeconomic status) and impaired diastolic performance (E/e' ratio difference 0.2) 31 years later among 1,871 individuals followed in the Cardiovascular Risk in Young Finns Study.

"These findings further emphasize that approaches of cardiovascular disease prevention must be directed also to the family environment of the developing child," the researchers concluded. "Particularly, support for families with low socioeconomic status may pay off in sustaining cardiovascular health to later life."

An accompanying editorial noted that the findings agreed with those of a similar longitudinal study from Britain from after World War II, although the mechanisms are not clear. "A life-course approach emphasizes the importance of identifying the period in the life course where intervention is likely to be most effective, and the study adds to the evidence pointing toward the importance of childhood."

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